Cellular Injury

7/27/2019 Cellular Injury

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M C Q i n P a t h o l o g y P a g e | 1

Cellular Injury

Question 1

A 48-year-old woman has a malignantlymphoma involving lymph nodes in

the para-aortic region. She is treated

with a chemotherapeutic agent which

results in the loss of individual

neoplastic cells through fragmentation

of individual cell nuclei and cytoplasm.

Over the next 2 months, the

lymphoma decreases in size, as

documented on abdominal CT scans.

By which of the following mechanismshas her neoplasm primarily responded

to therapy?

A Coagulative necrosis

B Mitochondrial poisoning

C Phagocytosis

D Acute inflammation

E Apoptosis

(E) CORRECT. The induction of

individual cell death occurs in the

process of apoptosis. The drug effect

is targeted primarily at neoplastic

cells, not normal cells.

Question 2

A 53-year-old man has experiencedsevere chest pain for the past 6 hours.

On physical examination he is afebrile,

but has tachycardia. Laboratory

studies show a serum troponin I of 10

ng/mL. A coronary angiogram is

performed emergently and reveals

>90% occlusion of the left anterior

descending artery. In this setting, an

irreversible injury to myocardial fibers

will have occurred when which of the

following cellular changes occurs?

A Glycogen stores are depleted

B Cytoplasmic sodium increases

C Nuclei undergo karyorrhexis

D Intracellular pH diminishes

E Blebs form on cell membranes

(C) CORRECT. Chromatin clumping is

reversible, but dissolution of the entire

nucleus is not, and when the nucleusis lost, the cell will die.

Question 3

While in a home improvement center

warehouse buying paint, a 35-year-old

man hears "Look out below!" and is

then struck on the leg by a falling

pallet rack, which strikes him on his

left leg in the region of his thigh. The

skin is not broken. Within 2 days thereis a 5 x 7 cm purple color to the site of

injury. Which of the following

substances has most likely

accumulated at the site of injury to

produce a yellow-brown color at the

site of injury 16 days later?

A Lipofuscin

B Bilirubin

C Melanin

D Hemosiderin

E Glycogen

(D) CORRECT. The iron in the heme

pigment from the red blood cells in the


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hemorrhage beneath the skin is

incorporated into hemosiderin

granules that impart the yellow to

brown color of the healing bruise.

Question 4

A54-year-old man with a chronic

cough has a squamous cell carcinoma

diagnosed in his right lung. While

performing a pneumonectomy, the

thoracic surgeon notes that the hilar

lymph nodes are small, 0.5 to 1.0 cm

in size, and jet black in color

throughout. Which of the following is

the most likely cause for this

appearance to the hilar nodes?

A Anthracotic pigment

B Lipochrome deposits

C Melanin accumulation

D Hemosiderosis

E Metastatic carcinoma

(A) CORRECT. The black color comesfrom carbon pigments in dust inhaled

over the years, engulfed by

macrophages, and sent via lymphatics

to the nodes. It looks bad but does not

compromise lung function. Smokers

will have more anthracosis.

Question 5

A 50-year-old woman with a history ofunstable angina suffers an acute

myocardial infarction. Thrombolytic

therapy with tissue plasminogen

activator (tPA) is administered to

restore coronary blood flow. In spite of

this therapy, the degree of myocardial

fiber injury may increase because of

which of the following cellular

abnormalities?

A Cytoskeletal intermediate filament

loss

B Decreased intracellular pH from

anaerobic glycolysis

C Increased free radicals

D Mitochondrial swelling

E Nuclear chromatin clumping and

decreased protein synthesis

F Reduced protein synthesis

(C) CORRECT. Such toxic oxygen

radicals are released from neutrophils

when blood flow is restored following

ischemia. This is a reperfusion injury.

Overall, there is likely to be more good

than harm to restoration of blood flow.

Question 6

A 12-year-old boy has had multiple

episodes of ear pain accompanied by

fever. On examination his right

tympanic membrane is red and

bulging with yellow exudate.

Laboratory studies of the exudate

show culture positive for Hemophilus

influenzae. A year later he has

conductive hearing loss on the right,

and a head CT scan shows a mass in

the right middle ear. Which of the

following materials is most likely to be

seen in the tissue curetted from his

middle ear?

A Lipofuscin

B Russell bodies


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C Neutrophils

D Cholesterol crystals

E Anthracotic pigment

(D) CORRECT. The lipid from the redcell membranes is broken down and

cholesterol crystals form. The boy has

the complication of otitis media known

as a cholesteatoma

Question 7

A 43-year-old man has complained of

mild burning substernal pain following

meals for the past 3 years. Upper GI

endoscopy is performed and biopsiesare taken of an erythematous area of

the lower esophageal mucosa 3 cm

above the gastroesophageal junction.

There is no mass lesion, no ulceration,

and no hemorrhage noted. The

biopsies show the presence of

columnar epithelium with goblet cells.

Which of the following mucosal

alterations is most likely represented

by these findings?

A Dysplasia

B Hyperplasia

C Carcinoma

D Ischemia

E Metaplasia

(E) CORRECT. Metaplasia is the

substitution of one tissue normallyfound at a site for another. The

esophageal epithelium undergoes

metaplasia in response to the ongoing

inflammation from reflux of gastric

contents. This is common in the lower

esophagus with gastroesophageal

reflux disease (GERD).

Question 8

A 59-year-old woman had the loss of

consciousness that persisted for over

an hour. When she becomes

arousable, she cannot speak nor move

her right arm or leg. A cerebral

angiogram revealed an occlusion to

her left middle cerebral artery. Months

later, a computed tomographic (CT)

scan shows a large 5 cm cystic area in

her left parietal lobe cortex. This CT

finding is most likely the consequence

of resolution from which of thefollowing cellular events?

A Liquefactive necrosis

B Atrophy

C Coagulative necrosis

D Caseous necrosis

E Apoptosis

(A) CORRECT. She had a 'stroke' with

loss of brain tissue. The brain

undergoes liquefactive necrosis with

infarction. As it resolves, macrophaes

remove the dead cells and debria,

leaving a cystic area that forms in the

region of infarction.

Question 9

A 19-year-old woman gives birth to

her first child. She begins breast

feeding the infant. She continues

breast feeding for almost a year with

no difficulties and no complications.

Which of the following cellular

processes that began in the breast


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during pregnancy allowed her to nurse

the infant for this period of time?

A Stromal hypertrophy

B Epithelial dysplasia

C Steatocyte atrophy

D Ductal epithelial metaplasia

E Lobular hyperplasia

(E) CORRECT. There is an increase in

the breast lobules under hormonal

influence with pregnancy to provide

for lactation.

Question 10

An 80-year-old man dies from

complications of Alzheimer disease. At

autopsy, his heart is small (250 gm)

and dark brown on sectioning.

Microscopically, there is light brown

perinuclear pigment with H&E staining

of the cardiac muscle fibers. Which of

the following substances is most likely

increased in the myocardial fibers to

produce this appearance of his heart?

A Hemosiderin from iron overload

B Lipochrome from 'wear and tear'

C Glycogen from a storage disease

D Cholesterol from atherosclerosis

E Calcium deposition following

necrosis

(B) (B) CORRECT. Lipochrome

deposition is a very common finding,

though ordinarily there are small

amounts of it, and it has little effect

upon cardiac function. The 'brown

atrophy' of the heart in this case is a

rare finding.

Question 11

In an experiment, a series of

immunohistochemical stains are

employed to identify different cellular

components. One particular stain

identifies the presence of intermediate

filaments within cells. This cytokeratin

stain is most likely to be useful for

which of the following diagnostic

purposes?

A Cytoskeletal alterations indicate

impending cell death

B A neoplasm is determined to be a

carcinoma

C Contractile properties of the cells

can be assessed

D A history of chronic alcoholism can

be confirmed

E The degree of metaplasia or

dysplasia can be assessed

(B) CORRECT. Carcinomas are derived

from epithelium and contain

cytokeratins, while sarcomas derived

from mesenchymal cells contain

vimentin.

Question 12

A 20-year-old woman had

Goodpasture syndrome which

progressed to chronic renal failure.

She was 165 cm tall and weighed 55

kg. She had blood pressure

measurements in the range of 150/90

to 180/110 mm Hg, but she did not

regularly take medications. Laboratory

studies showed her blood urea


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nitrogen was over 100 mg/dL. She

required chronic dialysis. She died

from heart failure. At autopsy, her

heart weighed 540 gm. The size of her

heart is most likely to be the result of

which of the following processesinvolving the myocardial fibers?

A Hypertrophy

B Fatty infiltration

C Hyperplasia

D Fatty degeneration

E Edema

(A) CORRECT. The ongoing pressure

load of the systemic hypertension led

to myocardial fiber hypertrophy and a

heart that increased to twice normal

size.

Question 13

A 29-year-old man goes on a

snorkeling trip to Looe Key Marine

Sanctuary and later spends time onthe beach at Bahia Honda State Park.

The next day he has a darker

complexion. His skin does not show

warmth, erythema, or tenderness. His

skin tone fades to its original

appearance within a month. Which of

the following substances contributes

the most to the biochemical process

leading to these skin changes?

A Iron oxide

B Lipofuscin

C Tyrosine

D Homogentisic acid

E Glycogen

(C) CORRECT. The tanning process in

skin is stimulated by ultraviolet light

exposure. Melanocytes have the

enzyme tyrosinase to oxidize tyrosine

to dihydroxyphenylalanine in the

pathway for melanin production.

Question 14

A study is performed to identify

predisposing risks for tissue changes.

In some persons epithelial metaplasia

occurs. In which of the following

situations is the process of epithelial

metaplasia most likely to take place?

A Tanning of the skin followingsunlight exposure

B Lactation following pregnancy

C Vitamin A deficiency

D Acute myocardial infarction

E Urinary obstruction from an

enlarged prostate

(C) CORRECT. Vitamin A is necessaryto maintain epithelia, and squamous

metaplasia of the respiratory tract

may occur if there is a deficiency. The

stratified squamous epithelium does

not function as well as the normal

pseudostratified columnar respiratory

epithelium, and there is an increased

risk for respiratory infections.

Question 15

In an experiment, a disease process is

found which leads to scattered loss of

individual cells, with the microscopic

appearance of karyorrhexis and cell

fragmentation. The overall tissue

structure remains intact. This process


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is most typical for which of the

following diseases?

A Viral hepatitis

B Brown atrophy of the heart

C Renal transplant rejection

D Chronic alcoholic liver disease

E Barbiturate overdose

(A) CORRECT. Viral infection leads to

apoptosis with individual hepatocyte

necrosis, either from effects of viral

replication or from the body's immune

response..

Question 16

A 60-year-old woman has noted a dark

red-black appearance to her great toe

and second and third toes of her left

foot for the past month. On physical

examination, the toes are cold to

touch and have no sensation to touch.

The dorsalis pedis and posterior tibial

pulses are not palpable on the left. Atransmetatarsal amputation is

performed. These findings are most

typical for a patient with which of the

following conditions?

A Diabetes mellitus

B Monckeberg arteriosclerosis

C Blunt force trauma

D AIDS

E Autoimmunity

(A) CORRECT. This is gangrenous

necrosis. Occlusive peripheral

atherosclerotic vascular disease is

typical for diabetes mellitus. Many

arteries are involved, reducing

collateral flow.

Question 17

A study is performed involving the

microscopic analysis of tissues

obtained from surgical procedures.

Some of these tissues have the

microscopic appearance of an

increased cell size of multiple cells

within the tissue, due to an increase in

the amount of cytoplasm, with nuclei

remaining uniform in size. Which of

the following conditions is most likely

to have resulted in this finding?

A Uterine myometrium in pregnancy

B Female breast at puberty

C Liver following partial resection

D Ovary following menopause

E Cervix with chronic inflammation

(A) CORRECT. This cellular

hypertrophy with increase in cell size(not hyperplasia with increase in cell

number) accounts for the marked

increase in size of the uterus during

pregnancy. Following pregnancy and

reduction in hormonal stimulation, the

uterus returns back to its normal size.

Question 18

A 17-year-old adolescent receives

whole body radiation as part of a

preparatory regimen for bone marrow

transplantation to treat acute

lymphocytic leukemia. Which of the

following cells and tissues in the body

is most likely to remain unaltered by

the effects of this therapeutic

radiation?


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A Ovarian follicles

B Small intestinal epithelium

C Erythropoietic cells of bone marrow

D Spermatogonia of testicular tubules

E Neurons of cerebral cortex

(E) CORRECT. Neurons are terminally

differentiated cells that do not actively

divide or proliferate. However, at

higher radiation doses, cerebral injury

does occur from damage mainly to

white matter and to the vasculature.

Question 19

A 79-year-old man has a large

myocardial infarction involving much

of the left ventricular free wall. He

develops congestive heart failure

(CHF) with decreased cardiac output.

Now, a year later, his CHF is

worsening. By echocardiography there

is a large, bulging akinetic area typicalfor a left ventricular aneurysm. Which

of the following laboratory tests on

serum would best indicate poor

peripheral tissue perfusion in this

patient?

A Elevated troponin I

B Increased sodium

C Elevated lactate

D Increased hematocrit

E Increased sedimentation rate

(C) CORRECT. Under conditions of poor

tissue perfusion, there will be more

anaerobic glycolysis and more acidosis

in cells throughout the body. The

blood lactate rises in this condition.

Question 20

A 22-year-old woman has a congenital

anemia. She has required multiple

transfusions of red blood cells for

many years. She now has no

significant findings on physical

examination. Laboratory studies now

show a serum AST of 74 U/L and ALT

75 U/L with albumin 3.6 g/dL. Which of

the following microscopic findings

would most likely appear in a liver

biopsy?

A Steatosis in hepatocytes

B Bilirubin in canaliculi

C Hemosiderin in hepatocytes

D Glycogen in hepatocytes

E Amyloid in portal triads

(C) CORRECT. There is 250 mg of iron

in each unit of blood. The body has no

mechanism for getting rid of excess

iron. A small amount of iron is lost with

normal desquamation of epithelia, and

menstruating women will lose a bit

more. The excess iron becomes

storage iron, or hemosiderin. Over

time, hemosiderosis involves more

and more tissues of the body,

particularly the liver.

Question 21

A 20-year-old man is involved in a

motor vehicle accident which results in

multiple blunt trauma and lacerations

to his lower extremities. The left


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femoral artery is lacerated, and he

incurs extensive blood loss and

remains hypotensive for hours during

transport to the emergency

department. On admission, his

hematocrit is 12%. Which of thefollowing tissues is most likely to

withstand the impact of these events

with the least damage?

A Skeletal muscle

B Small intestinal epithelium

C Retina

D Myocardium

E Hippocampus

(A) CORRECT. The skeletal muscle

tissue is the least metabolically active

of the ones listed, and is also able to

function with anaerobic glycolysis.

Question 22

A 40-year-old woman has the sudden

onset of severe abdominal pain. Onphysical examination she has diffuse

tenderness in all abdominal quadrants,

with marked guarding and muscular

rigidity. She has laboratory findings

that include serum AST of 43 U/L, ALT

of 30 U/L, LDH 630 U/L, and lipase 415

U/L. An abdominal CT scan reveals

peritoneal fluid collections and

decreased attenuation along with

enlargement of the pancreas. Which of

the following cellular changes is mostlikely to accompany these findings?


B Dry gangrene

C Fat necrosis

D Apoptosis

E Liquefactive necrosis

(C) CORRECT. The enzymes releasedfrom the pancreas with acute

pancreatitis damage the surrounding

fat and form soaps -- localized soft tan

to yellow areas of fat necrosis. The

damaged pancreatic exocrine cells

release lipase and amylase as markers

for their injury.

Question 23

A 26-year-old man died from

complications of destruction of the

aortic valve by large, irregular

vegetations from which

Staphylococcus aureus was cultured.

At autopsy, the spleen on sectioning

grossly reveals the presence of a tan

to white, wedge-shaped 1.5 x 3 cm

lesion with base on the capsule. The

splenic findings are most likely toresult from which of the following

cellular abnormalities?


B Abscess formation

C Metaplasia

D Caseous necrosis

E Liquefactive necrosis

(A) CORRECT. The description is that

of a typical infarct with vascular

occlusion following embolization from

vegetations of infective endocarditis.


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Question 24

A 35-year-old woman developed

increasing icterus over the last week

of life. Laboratory studies had shown

hyperammonemia. She is found atautopsy to have a 3500 gm liver with

a uniform, yellow, greasy cut surface.

No necrosis of hepatocytes is noted

microscopically. This pathologic

appearance of the liver most likely

resulted from which of the following

conditions?

A Galactosemia

B Hemochromatosis

C Tuberculosis

D Alcoholism

E Hypoxemia

(D) CORRECT. The marked fatty

change of the liver with hepatomegaly

is a typical sequel of chronic alcoholabuse.

Question 25

A clinical study is performed in which

the conditions leading to the

appearance of calcification on chest

and abdominal CT scans are analyzed

in patients from 60 to 90 years of age.

One set of patients has the finding of

incidental calcification, with no serious

health problems. In which of the

following tissue locations was this

incidental calcification most likely to

be noted?

A Coronary artery

B Renal cortex

C Mitral valve

D Pulmonary parenchyma

E Aortic arch

(E) CORRECT. Such calcification iscommonly seen in adults, and though

part of atherosclerosis, would not have

major consequences if mild to

moderate because the function of the

aorta in carrying blood would not be

seriously compromised.

Question 26

A 55-year-old man has a 30-year

history of poorly controlled diabetesmellitus. He has had extensive black

discoloration of skin and soft tissue of

his right foot, with areas of yellowish

exudate, for the past 2 months.

Staphylococcus aureus is cultured

from this exudate. A below-the-knee

amputation is performed. The

amputation specimen received in the

surgical pathology laboratory is most

likely to demonstrate which of the

following pathologic abnormalities?

A Neoplasia

B Gangrene

C Coagulopathy

D Hemosiderosis

E Caseation

(B) CORRECT. Gangrenous necrosis isa typical complication of diabetes

mellitus with marked peripheral

vascular disease. Gangrene is a form

of coagulative necrosis that involves a

body part, including several tissues.

The infection adds an element of


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liquefactive necrosis, best described

as 'wet gangrene.'

Question 27

The lifestyle patterns of healthy

persons from 20 to 30 years of age are

studied. A subset of these persons

have a lifestyle characterized by

consumption of a lot of pizza and very

little physical exercise. Which of the

following tissue changes is most likely

to develop in this subset of persons as

a consequence of this lifestyle?

A Fatty metamorphosis of liver

B Pancreatic fat necrosis

C Fatty degeneration of myocardium

D Hypertrophy of steatocytes

E Metaplasia of muscle to adipose

tissue

(D) CORRECT. The fat cells

(adipocytes) increase in size

(hypertrophy) with obesity in adults,and this is the predominant effect of

weight gain.

Question 28

In an experiment, a tissue preparation

is subjected to oxidant stress. There

are increased numbers of free radicals

generated within the cells. Generation

of which of the following substances

within these cells is the most likely

protective mechanism to reduce the

number of free radicals?

A Glutathione peroxidase

B Catalase

C Hydrogen peroxide

D NADPH oxidase

E Myeloperoxidase

(A) CORRECT. The glutathione

peroxidase system is designed to help

break down free radicals generated

from various forms of cell injury. This

system works in the background with

small numbers of free radicals.

Disease processes with greater

amounts of cell injury can overwhelm

this system.

Question 29

A 38-year-old man incurs a traumatic

blow to his upper left arm. He

continues to have pain and tenderness

even after 3 months have passed. A

plain film radiograph reveals a 4 cm

circumscribed mass in the soft tissue

adjacent to the humerus. The mass

contains areas of brightness on the x-

ray. Over the next year this process

gradually resolves. Which of the

following terms best describes this

process?

A Dysplasia

B Hyperplasia

C Hypertrophy

D Metaplasi

E Neoplasia

(D) CORRECT. The brightness on x-ray

suggests calcification from osseous

metaplasia of connective tissues that

developed in the healing process. This

condition is known as myositis


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ossificans, because there is bone

formation in the injured muscle.

Question 30

A 31-year-old primigravida has a

difficult delivery of a term infant, with

loss of 1500 cc of blood. She has

hypotension for 6 hours. Over the next

month, her ACTH level decreases.

Within the next 3 months, her adrenal

glands become only about 2 grams

each (normal 4 to 6 grams). This

alteration of the adrenals is primarily

due to which of the following cellularprocesses?

A Metaplasia

B Lipid depletion

C Apoptosis

D Autophagocytosis

E Coagulative necrosis

(D) CORRECT. The loss of ACTH leads

to cortical atrophy from cellular

downsizing, with the consequence of

decreased glucocorticoid and

mineralocorticoid production.

Question 31

A 48-year-old man has a history of

chronic alcohol abuse. He is still able

to perform work at his job. He has had

no major illnesses. On physicalexamination, there are no significant

findings. Laboratory studies show a

serum albumin of 4.1 g/dL, ALT 40 U/L,

AST 40 U/L, and total bilirubin 1.1

mg/dL. Which of the following

microscopic findings in his liver is

most likely to be present?

A Cholestasis

B Fatty change

C Hemochromatosis

D Hypertrophy of smooth

endoplasmic reticulum

E Coagulative necrosis

(B) CORRECT. The toxic effects of the

alcohol culminate in large lipid droplet

accumulation within hepatocytes.

Over time, more hepatocytes areaffected and the liver is less able to

compensate.

Question 32

A 44-year-old woman has had

episodes of right upper quadrant pain

during the past 2 weeks. Her stools

have become pale in color over the

past 3 days. Laboratory studies show a

serum total bilirubin of 9.7 mg/dL. Acholangiogram shows that a gallstone

has passed into the common bile duct,

resulting in obstruction of the biliary

tract. Which of the following cellular

alterations is most likely to be

visualized on her skin surfaces?

A Hemosiderosis

B Calcification

C Lipofuscin deposition

D Icterus

E Steatosis

(D) CORRECT. She probably has a

'jaundiced' appearance to her sclerae


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and skin due to the increased amount

of bilirubin. The bile pigments impart a

yellow color to the tissues. She has

biliary tract obstruction from

cholelithiasis and choledocholithiasis.

Question 33

A 45-year-old man has a traumatic

injury to his forearm and incurs

extensive blood loss. On physical

examination in the emergency

department his blood pressure is

70/30 mm Hg. Which of the following

cellular changes is most likely torepresent irreversible cellular injury as

a result of this injury?

A Epithelial dysplasia

B Cytoplasmic fatty metamorphosis

C Nuclear pyknosis

D Atrophy

E Anaerobic glycolysis

F Autophagocytosis

(C) CORRECT. The hypotension leads

to diminished tissue perfusion with

ischemic injury. Nuclear chromatin

clumping is reversible, but nuclear

pyknosis is not.

Question 34

A 73-year-old man suffers a "stroke."On physical examination he cannot

move his right arm. A cerebral

angiogram demonstrates occlusion of

the left middle cerebral artery. An

echocardiogram reveals a thrombus

within a dilated left atrium. Which of

the following is the most likely

pathologic alteration from this event

that has occurred in his brain?

A Cerebral softening from liquefactive

necrosis

B Pale infarction with coagulative

necrosis

C Predominantly the loss of glial cells

D Recovery of damaged neurons if

the vascular supply is reestablished

E Wet gangrene with secondary

bacterial infection

(A) CORRECT. Liquefactive necrosistypifies brain infarction. The brain

tissue contains abundant lipid. After

the initial softening, tissue

macrophages will increase and clear

the debris, leaving a cystic space.

Since neurons cannot regenerate, the

size of the infarct determines the

amount of functional loss. The brain

has some capacity for rewiring, but

this diminishes with age.

Question 35

A 30-year-old woman is claiming in a

civil lawsuit that her husband has

abused her for the past year. A

workup by her physician reveals a 2

cm left breast mass. There is no

lymphadenopathy. No skin lesions are

seen, other than a bruise to her upper

arm. An excisional biopsy of the breast

mass is performed. On microscopicexamination, the biopsy shows fat

necrosis. This biopsy result is most

consistent with which of the following

etiologies?

A Physiologic atrophy


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B Breast trauma

C Lactation

D Radiation injury

E Hypoxic injury

(B) CORRECT. Fat necrosis is seen with

trauma to the breast, and her lawyer

will make good use of that

documentation. The pattern of

multiple injuries of differing ages at

different sites suggests abuse.

Question 36

A 45-year-old man has smoked 2

packs of cigarettes per day for the

past 30 years. He has had a chronic

cough for the past 3 years, worsening

over the past 2 weeks. A suspicious

left pulmonary parenchymal lesion is

seen on a chest x-ray. He has a

bronchoscopy performed. A biopsy of

a segmental bronchus shows

squamous metaplasia. Which of thefollowing is the most appropriate

interpretation of this finding?

A Ischemic tissue damage

B Irritant effect

C Early stage of cancer

D Viral infection

E Congenital anomaly

(B) CORRECT. The irritant effect, such

as the various chemicals in cigarette

smoke, leads to replacement of the

normal epithelium with another (such

as squamous epithelium replacing

respiratory epithelium). This

metaplastic process is the first step

that could lead to dysplasia and then

to neoplasia. Note that histologists call

any flattened epithelium a 'squamous'

epithelium, but pathologists refer to

specific cell types, and consider a truesquamous epithelium to be a stratified

squamous epithelium.

Question 37


congestive heart failure for the past 4

years. She develops a fever that

persists for over a week. On physical

examination, a heart murmur is

present. Her temperature is 38.4 C.The spleen tip is palpable. On

echocardiography she has an

abnormally thickened mitral valve.

Laboratory studies show a blood

culture positive for Streptococcus,

viridans group. Another

echocardiogram reveals a 1 cm

vegetation on the superior aspect of

her mitral valve. Which of the

following findings would you most

expect to appear in the kidney as a

consequence of these events?

A Marked passive congestion

B Ischemic infarct

C Extensive edema

D Granulomatous inflammation

E Gangrenous necrosis

(B) CORRECT. Friable mitral valvular

vegetations from infective

endocarditis can embolize into the

systemic circulation. Occlusion of a

branch of the arterial supply to an

organ can result in an infarction, which


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is characterized by the appearance of

coagulative necrosis in most visceral

organs.

Question 38

A 19-year old G2 P1 woman has an

amniocentesis performed at 18 weeks

gestation. Fibroblasts recovered from

amniocentesis are grown in culture to

assess the karyotype of fetal cells.

These cells are subcultured for

additional experimental work, but the

culture is lost after 50 doublings of the

cells has occurred, and the fibroblasts

no longer grow. Which of the following

factors affecting these cells is mostlikely demonstrated by this

phenomenon?

A Nutrition

B Mutation

C Apoptosis

D Aging

E Oxidation

(D) CORRECT. A number of factors

play a role in aging, but the lack of

immortality of individual cells is one

feature. The lack of telomerase

activity in most cells prevents

repeated division. Stem cells have

greater replicative capacity.

Question 39

A 55-year-old man has sudden onset

of severe, sharp chest pain with

diaphoresis and dyspnea. On physical

examination he has tachycardia with

an irregular heart rhythm.

Electrocardiographic changes suggest

the possibility of focal myocardial

damage involving the left lateral

ventricular wall. Which of the following

laboratory tests on the patient's serum

is most useful in this situation?

A Total cholesterol

B Creatine kinase

C Triglyceride

D Amylase

E Sedimentation rate

(B) CORRECT. The CK will be elevatedwith myocardial ischemic injury. The

CK-MB isoenzyme fraction is most

specific for cardiac muscle, while CK-

MM is most specific for skeletal

muscle. Another very specific analyte

for cardiac striated muscle injury is

troponin. Myoglobin is a sensitive, but

not specific marker for myocardial

injury, because it could also be

released from skeletal muscle.

Question 40

A 42-year-old previously healthy

woman notes that over the past week

her eyes have developed a yellowish

appearance. She has had mild nausea

and vomiting over the past week. On

physical examination she has scleral

icterus. She has no other majorphysical examination findings except

for mild right upper quadrant

tenderness. Which of the following

underlying conditions is most likely to

contribute to development of her

icterus?


15/19


A Hypercholesterolemia

B Thrombocytopenia

C Metastatic carcinoma

D Viral hepatitis

E Diabetes mellitus

(D) CORRECT. Hepatitis, most often an

infectious viral hepatitis, leads to liver

cell dysfunction with impaired uptake,

conjugation, and excretion of bilirubin.

As a result there is an increasing

serum bilirubin that produces the

jaundice (icterus).

Question 41

A 56-year-old woman has smoked 2

packs of cigarettes per day for the

past 35 years. She has had a chronic

cough for the past 8 years, but

recently has noted increased sputum

production. On physical examination

she has a few crackles auscultatedbest over the lung bases.

Bronchoscopy with biopsy is

performed. The biopsy reveals

bronchial epithelium with squamous

metaplasia. Which of the following

statements represents the best

interpretation of these findings?

A This is a physiologic process of

aging

B This process is irreversible, even if

she stops smoking

C She has metastases to lung from a

primary somewhere else

D She has an increased risk for

pulmonary infection

E A pulmonary thromboembolus

caused pulmonary infarction

(D) CORRECT. The loss of normal

functioning respiratory epithelium

means that the normal barrier toinfection has been weakened.

Question 42

A 90-year-old woman dies from

pneumonia complicating Parkinson

disease. At autopsy her heart is

normal in size. On microscopic

examination, there is increased

lipochrome (lipofuscin) seen adjacent

to the nuclei within the myocardial

fibers. This microscopic finding is most

likely to result from which of the

following cellular mechanisms?

A Nuclear pyknosis

B Myocardial fiber hypertrophy

C Coagulative necrosis

D Autophagocytosis

E Anaerobic glycolysis

(D) CORRECT. The lipochrome

represents the residual debris of

organelles and appears with increased

frequency with aging, particularly in

heart and liver.

Question 43

An experiment is conducted to

determine if cell membrane injury is

lessened by the effects of vitamin E

ingestion. Which of the following

cellular components is primarily

involved in generation of lipid


16/19


peroxides, the formation of which is

inhibited by the vitamin E?

A Glutathione

B Ionized calcium

C Lactate

D Ferric iron

E Lipase

(D) CORRECT. Ferric ion is needed for

reduced oxygen species to injure cells.

Hydroxyl radicals initiate lipid

peroxidation.

Question 44


headaches and abdominal pain

worsening for 3 months. There are no

remarkable physical examination

findings. On radionucleide scanning of

the neck, she is found to have a mass

involving one of her parathyroid

glands. An abdominal CT scan

suggests extensive nephrocalcinosisalong with urinary tract calculi. Which

of the following laboratory test

findings is most likely to accompany

her disease?

A CO2 of 30 mmol/L

B Phosphorus of 2.2 mg/dL

C Uric acid of 15.1 mg/dL

D Sodium of 121 mmol/L

E Calcium of 4.5 mg/dL

(B) CORRECT. Metastatic calcification

occurs as a result of a high serum

calcium, which in the case of

hyperparathyroidism is accompanied

by a low serum phosphorus.

Question 45

A 21-year-old woman has a routine

Pap smear performed for a health

screening examination. The pathology

report indicates that some cells are

found cytologically to have larger,

more irregular nuclei. A follow-up

cervical biopsy microscopically

demonstrates disordered maturation

of the squamous epithelium, with

hyperchromatic and pleomorphic

nuclei extending nearly the full

thickness of the epithelial surface. Noinflammatory cells are present. Which

of the following descriptive terms is

best applied to these Pap smear and

biopsy findings?

A Dysplasia

B Metaplasia

C Anaplasia

D Hyperplasia

E Aplasia

(A) CORRECT. Disordered growth of an

epithelium is seen in dysplasia, which

can be a precursor to neoplasia. When

the term 'dysplasia' is used in

pediatric conditions, it refers to

disordered development of a tissue,

including cell types that ordinarily are

not present. In adults, dysplasia refersto an abnormal change in an

epithelium, beyond physiologic

alteration, that is starting down the

road to cancer.

Question 46


17/19


A 38-year-old man has a health

screening examination. He has a

routine chest x-ray that shows a 2 cm

nodule in the right lower lobe. Thenodule has focal calcifications. A

wedge resection of the nodule is done.

On microscopic examination the

nodule shows caseous necrosis and

calcification. Which of the following

processes explains the appearance of

the calcium deposition:

A Dystrophic calcification

B Apoptosis

C Hypercalcemia

D Metastatic calcification

E Excessive ingestion of calcium

(A) CORRECT. Calcium is deposited in

and around the granuloma as a

reaction to injury with necrosis. Most

pulmonary granulomas are the result

of infection, typically tuberculosis.

Question 47

A 3-year-old child has been diagnosed

with ornithine transcarbamylase

deficiency and has developed hepatic

failure. The left lobe of an adult donor

liver is used as an orthotopic

transplant. A year later, the size of

each liver in donor and recipient is

greater than at the time oftransplantation. Which of the following

cellular alterations is most likely to

explain this phenomenon?

A Metaplasia

B Dysplasia

C Hyperplasia

D Anaplasia

E Neoplasia

(C) CORRECT. After removal of part ofthe liver, remaining liver can undergo

hyperplasia to compensate.

Hepatocytes are stable cells that are

able to re-enter the cell cycle.

Question 48

A morbidly obese 51-year-old woman

dies from complications of heartdisease. At autopsy, her heart weighs

600 gm (normal up to 300 gm) with all

the chambers enlarged.

Microscopically, there is increased

fibrous connective tissue seen in the

interstitium between myocardial

fibers. The fibers are increased in size.

Beneath the epicardium can be seen

adipocytes interdigitating with the

myocardial fibers. Which of the

following terms best describes thepresence of the adipocytes in her

myocardium?

A Steatosis

B Lipid degeneration

C Fatty infiltration

D Cholesterolosis

E Xanthomatosis

(C) CORRECT. The adipocytes are

normal fat cells. Obese persons just

have more of them, and the individual

cells are larger, making them more

obvious and prominent on

examination. Their presence in the


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superficial myocardium is more a

marker of obesity than a risk for

myocardial failure.

Question 49

A 48-year-old man has an episode of

severe substernal chest pain radiating

to his left arm. Four months later he

has increasing dyspnea and

orthopnea. On physical examination

there are rales heard over all lung

fields. An echocardiogram shows a left

ventricular aneurysm. He has

decreased cardiac output with an

ejection fraction of 29%. Which of the

following findings is most likely to beindicative of the original acute event

at the time he presented with chest

pain?

A Troponin I release from myofibers

B Collagenous scar tissue in the

myocardium

C Chronic passive congestion of the

liver

D Organizing mural thrombus in left

ventricle

E Recanalization of a coronary artery

thrombosis

(A) CORRECT. Elevations in troponin I

or T and in the creatine kinase (CK)

enzymes, particularly CK-MB fraction,

as well as serum myoglobin, are going

to be seen acutely with a myocardialinfarction.

Question 50

A 53-year-old man suffers a cardiac

arrest and his wife calls emergency

services. The paramedics arrive a few

minutes later and begin life support

measures. A regular heart rate is

established after about 40 minutes ofresuscitative efforts as he is being

transported to the hospital. A

thrombolytic agent (tPA) is

administered. Which of the following

cellular processes is most likely to

occur in his myocardium following

administration of the tPA?

A Apoptosis

B Free radical injury

C Heterophagocytosis

D Squamous metaplasia

E Accumulation of cytokeratins

(B) CORRECT. The ischemia during the

cardiac arrest followed by reperfusion

established following successful

resuscitation will generate activated

oxygen species to produce free radicalinjury.

Question 51

A 38-year-old woman has severe

abdominal pain with hypotension and

shock that has developed over the

past 36 hours. On physical

examination, her abdominal musclesare rigid and her abdomen is

extremely tender. An abdominal CT

scan reveals fluid density in the region

of the pancreas, which appears to be

enlarged. Which of the following

laboratory test findings in her serum is

most likely to be present?


19/19


A Alanine aminotransferase of 1123

U/L

B Total cholesterol of 324 mg/dL

C Creatine kinase of 869 U/L

D Urea nitrogen of 110 mg/dL

E Lipase of 1134 U/L

(E) CORRECT. There is evidence for

acute pancreatitis with edema and

necrosis. The necrosis is typically fat

necrosis with grossly visible focal

chalky-white deposits representing

areas of saponification as a

consequence of release of pancreaticenzymes (lipase and amylase) with

acute inflammation.

Question 52

A 45-year-old man has noted scleral

icterus for the past 4 days. He has

been feeling tired and "run down" for

about a month. On physical

examination, other than mild

tachycardia, his vital signs are normal.No other physical examination findings

are of noted other than scleral icterus.

Laboratory studies show a hematocrit

of 25%. Which of the following

conditions is most likely to account for

these findings?

A Systemic hypertension

B Excessive iron absorption

C Diabetes mellitus, type I

D Intravascular hemolysis

E Pulmonary squamous cell

carcinoma

(D) CORRECT. The increased turnover

of red blood cells leads to increased

bilirubin production to cause the

icterus, as the amount of bilirubin

generated exceeds the capacity of the

liver to conjugate and excrete it intothe bile. This also explains his anemia

Question 53

A 49-year-old man with a history of

alcohol abuse has increasing

abdominal girth. On examination his

liver edge is firm. A liver biopsy shows

cirrhosis, and individual hepatocytes

contain red, globular inclusions

positive for cytokeratin withimmunohistochemical staining. Which

of the following structural elements

are these intracellular globules most

likely to contain?

A Actin and myosin

B Cholesterol esters

C Fatty acids

D Fibronectin

E Intermediate filaments

F Microtubules

(E) CORRECT. Intermediate filaments

may collect in the damaged

hepatocytes as the globular hyaline

known as Mallory hyaline. It is

characteristic for alcoholic liver

disease, but not pathognomic for it.

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Cellular Injury